Recreational drugs: relationship to AIDS

Current data suggest that a transmissible agent causes AIDS, but undefined cofactors may also play a role. This paper reviews published data on the relationship between recreational drugs and immune alterations, with particular emphasis on nitrite inhalant (NI) use by homosexual men. In our original cohort of 15 homosexual men, helper:suppressor (H:S) T-cell ratios are stable, but persistently lower in the NI users. A recent analysis of 245 homosexual men shows that NI use is associated with low H:S ratios in homosexual men in Washington, D.C., but not in New York. Although NI use could increase the risk of AIDS by direct or indirect effects, it could also be a surrogate for a lifestyle practice that predisposes homosexual men to the putative AIDS agent. The current evidence concerning use of NI and the risk of AIDS is inconclusive, as is true for two other recreational drugs, heroin and cocaine. Future studies may not be able to dissect the complex interrelationships of drug use and other variables until precise laboratory tests are available for defining exposure to the putative AIDS agent and suspect cofactors.

Mortality associated with mode of presentation in the acquired immune deficiency syndrome

A population-based survival study was done for all cases of the acquired immune deficiency syndrome diagnosed in the city of San Francisco through May 1983. Follow-up was obtained for 165 of 173 diagnosed cases. Median survival among 75 patients presenting with Kaposi's sarcoma (KS) alone was 21 months. Median survival among 90 patients presenting with opportunistic infections, primarily Pneumocystis carinii pneumonia, was 9 months; survival at 21 months was zero. Survival among patients presenting with both KS and opportunistic infections was not statistically different from survival among patients presenting with opportunistic infections only. When cases were divided into those diagnosed before and after May 1982, there was no significant improvement in survival from diagnosis in the more recently diagnosed cohort.

Tuberculosis, atypical mycobacteriosis, and the acquired immunodeficiency syndrome among Haitian and non-Haitian patients in south Florida

To study the association between mycobacterial disease and the acquired immunodeficiency syndrome, we reviewed the records of all cases of tuberculosis and all cases of the syndrome reported in Dade County, Florida, from January 1980 through June 1983. Tuberculosis was diagnosed in 27 of 45 Haitians with the syndrome, but in only 1 of 37 non-Haitians with the syndrome (p less than 0.001). Among the 27 Haitians with the syndrome and tuberculosis, 19 had extrapulmonary tuberculosis, whereas among 286 Haitian patients with tuberculosis without the syndrome, only 56 had extrapulmonary tuberculosis (p less than 0.001). Tuberculosis preceded the syndrome by 1 to 17 months (mean, 6) in 22 patients. In 10 patients with the syndrome and positive sputum cultures who were treated with conventional antituberculosis drugs, the cultures became negative within 1 to 4 months and tuberculosis did not recur. The frequency of disseminated atypical mycobacteriosis or positive sputum cultures for atypical mycobacteria was not significantly different between Haitian (11.3%) and non-Haitian (8.3%) patients with the syndrome.

Inactivation of lymphadenopathy associated virus by chemical disinfectants

Reverse transcriptase activity of lymphadenopathy associated virus was assayed after exposure to various standard chemical disinfectants. 25% ethanol or 1% glutaraldehyde should prove sufficient to disinfect medical instruments, and 0.2% sodium hypochlorite for cleaning floors and benches. 0.1% formalin is too slow to be recommended.

Treatment of immunodeficiency with interleukin-2: initial exploration

Fifteen patients with acquired immunodeficiency syndrome (AIDS), lymphoma and immunodeficiency, or severe combined immunodeficiency were treated with highly purified interleukin-2 (IL-2) prepared from human lymphocytes. All patients showed a defect in mitogen-induced T cell proliferation which was partially corrected when IL-2 was added in vitro. IL-2 was administered subcutaneously by daily injection or continuous infusion. The maximum daily dose was 20,000 U/m2, the maximum total dose 855,000 U/m2, and the maximum period of treatment 77 days. An increase in the platelet count was seen in one patient with AIDS, a decrease in the serum level of a monoclonal immunoglobulin in another patient with AIDS, and a minor tumor response in a patient with diffuse histiocytic lymphoma. As no toxicity was observed, further study of IL-2 in the treatment of human immunodeficiency is indicated.

Systemic administration of interleukin-2 in humans

Twelve patients were treated in a Phase I trial of purified human interleukin-2 (IL-2) derived from the JURKAT cell line (E.I. duPont Corp., Glenolden, PA, U.S.A.). The serum half-life, toxicity, and in vivo immunologic effects of IL-2 were studied in patients with cancer unresponsive to standard therapy and in patients with acquired immunodeficiency syndrome (AIDS). Patients received 0.25, 2.5, or 25 micrograms/kg IL-2 by bolus or 24-h continuous infusion on a weekly basis for 4 weeks. The serum half-life of JURKAT IL-2 in humans was approximately 6 min. At higher doses of IL-2 a second component of clearance with a half-life of 30-120 min was found. Acute toxicity was minimal and consisted of headache (6 of 12), nausea (4 of 12), malaise (6 of 12), and fever and chills (8 of 12). No evidence of pulmonary, hematologic, or renal toxicity or any evidence of autoimmune phenomena was detected. A transient hyperbilirubinemia was seen in two patients receiving 2 mg purified IL-2. No demonstrable effect on tumors or chronic immunodeficiency (AIDS) was seen. No consistent chronic immunologic effects (natural killer or lymphokine-activated killer activity, mitogen responsiveness, total lymphocyte counts, or change in the proportion of various mononuclear cell phenotypes as defined by monoclonal antibody) were seen on a week-to-week basis during or following therapy. Acute changes in lymphokine responsiveness, the ability to generate lymphokine-activated killers, and an increase in macrophages in the mononuclear population were noted following administration of 1-2 mg IL-2.

Use of interleukin-2 in patients with acquired immunodeficiency syndrome

Twelve patients with acquired immunodeficiency syndrome were treated with a natural product, highly purified human interleukin-2. Doses ranged from 250 to 250,000 units. No clinical responses were seen. Minimal toxicity was noted and consisted of mild prolongation of partial thromboplastin time and proteinuria. Immunologic changes during the study included a decrease in the number of circulating T8 lymphocytes, increased skin test reactivity, and a decline in serum immunoglobulin levels.

Determinants of retrovirus (HTLV-III) antibody and immunodeficiency conditions in homosexual men

A cohort of homosexual men at high risk of the acquired immunodeficiency syndrome (AIDS) was monitored to examine the relation between lifestyle, clinical conditions, T-lymphocyte subsets, and antibody to the AIDS-associated human retrovirus, human T-cell leukaemia virus III (HTLV-III). HTLV-III antibodies were present in 35 (53%) of the 66 subjects tested in June, 1982. 4 of the seronegative subjects had HTLV-III antibodies when re-tested one year later, a seroconversion rate of 1.2% per month. In the HTLV-III seropositive subjects, AIDS developed at a rate of 6.9% per year (minimum incidence of AIDS = 4.6% per year) and other clinical signs of immunodeficiency (lesser AIDS) at 13.1% per year. All 6 of the AIDS cases and at least 8 of the 10 lesser AIDS cases had detectable HTLV-III antibodies 1 week to 21 months before diagnosis. Of 24 other subjects with stable lymphadenopathy, 19 (79%) had or acquired HTLV-III antibodies. Lower helper T-cell counts were very closely related to HTLV-III seropositivity (r = -0.53, p = 0.0001), even in the 26 healthy subjects with no clinical abnormalities (r = -0.37, p = 0.07). In both univariate and multivariate analyses, the lifestyle risk factors for HTLV-III seropositivity were large number of homosexual partners (p less than or equal to 0.03) and receptive anal intercourse (p less than or equal to 0.03), with an apparent synergistic interaction between these two activities (chi 2 = 8.71, p = 0.003). These data suggest that frequent receptive anal intercourse with many homosexual partners predisposes to HTLV-III infection with the consequent emergence of lymphadenopathy and the various manifestations of lesser and fully fledged AIDS.

Possible viral interactions in the acquired immunodeficiency syndrome (AIDS)

Viral interactions may occur whenever a host is infected simultaneously with two viruses. Persons at high risk for acquired immunodeficiency syndrome (AIDS) may provide a substrate for such interactions. These could include complementary immunosuppression, potentiation of infection by altered receptors or genetic complementation, phenotypic mixing, or genetic recombination. The possibility of such interactions should be considered in the pathogenesis of AIDS.

Acquired immunodeficiency syndrome in a heterosexual population in Zaire

38 patients with the acquired immunodeficiency syndrome (AIDS) were identified in Kinshasa, Zaire, during a 3 week period in 1983. The male to female ratio was 1.1:1. The annual case rate for Kinshasa was estimated to be at least 17 per 100 000. Opportunistic infections were diagnosed in 32 (84%) patients, disseminated Kaposi's sarcoma (KS) with opportunistic infection in 5 (13%), and disseminated KS alone in 1 patient. Immunological characteristics of these patients were as reported for cases in the USA and Europe, but immunological abnormalities were also found in 6 controls with infectious diseases but no symptoms of AIDS. Female AIDS cases were younger than male patients with AIDS (mean ages 28.4 vs 41.1 years, respectively), and were more often single (14/18 vs 2/20). Homosexuality, intravenous drug abuse, and blood transfusion did not appear to be risk factors in these patients. The findings of this study strongly argue that the situation in central Africa represents a new epidemiological setting for this worldwide disease--that of significant transmission in a large heterosexual population. Two instances of clusters of AIDS (not included in the above series) involving males and females with frequent heterosexual contact further implicate heterosexual transmission.

Acquired immunodeficiency syndrome in Rwanda

To evaluate acquired immunodeficiency syndrome (AIDS) in central Africa a prospective study was done in Kigali, Rwanda, where Kaposi's sarcoma (KS) is endemic. During a 4 week period, 26 patients (17 males and 9 females) were diagnosed. 16 patients had opportunistic infections, associated with KS in only 2; 1 had multifocal KS alone; and 9 had clinical conditions consistent with prodromes of AIDS. All patients had severe T-cell defects characterised by cutaneous anergy, a striking decrease in the number of helper T cells, and a decreased OKT4:OKT8 ratio (mean 0.27). 21 of the 22 adult patients were living in urban centres and many of them were in the middle to upper income bracket. Most of the men were promiscuous heterosexuals and 43% of the females were prostitutes. No patient had a history of homosexuality, intravenous drug abuse, or transfusion in the previous 5 years. This study suggests that AIDS is present in central Africa as an entity probably unrelated to the well-known endemic African KS. An association of an urban environment, a relatively high income, and heterosexual promiscuity could be a risk factor for AIDS in Africa.

Aggressive Kaposi's sarcoma in Zambia, 1983

From 1975 to 1982 between 8 and 12 new cases of Kaposi's sarcoma (KS) were seen each year in Lusaka, Zambia, and the clinical presentation and tumour behaviour conformed to descriptions of endemic KS from Uganda and Kenya. 23 patients presented with KS in 1983. 10 men, mean age 41, presented with typical symptoms and signs (nodules or plaques on oedematous limbs, with florid tumours or woody infiltration) and all 10 patients responded promptly to actinomycin D and vincristine. 13 patients (10 men and 3 women), mean age 27, presented with unusual symptoms and signs, including generalised symmetrical lymphadenopathy, oral or gastrointestinal lesions, respiratory distress, gross weight loss, and absence of nodules or plaques on the limbs. 8 of 13 patients with atypical KS failed to maintain an initial response to chemotherapy and died before the end of 1983, but there were no deaths amongst patients with endemic disease.

Longitudinal study of persistent generalised lymphadenopathy in homosexual men: relation to acquired immunodeficiency syndrome

42 homosexual or bisexual men with persistent generalised lymphadenopathy not attributable to an identifiable cause have been followed longitudinally since February, 1981. Lymphadenopathy was accompanied by fatigue, low-grade fever and/or night sweats (57%), splenomegaly (29%), leucopenia (40%), hypergamma - globulinaemia (76%), and diminished proportion and absolute numbers of helper T cells (95%). Of the 26 patients who had lymph node biopsy, all showed benign reactive hyperplasia. After 15-30 (median 22) months, 8 patients have met criteria for the diagnosis of acquired immunodeficiency syndrome (AIDS). This outcome was associated with previous heavy nitrite inhalant use, with the presence of night sweats, with leucopenia, and with the triad of constitutional symptoms, splenomegaly, and leucopenia. In addition, a lower mean absolute helper T cell count and an increased frequency of anergy to mumps intradermal antigen and of herpes simplex virus isolation distinguished these patients from those remaining in the cohort, who seem to be stable and in some cases to have improved.

Acquired immunodeficiency syndrome in African patients

Between May 1979 and April 1983, 18 previously healthy African patients were hospitalized in Belgium with opportunistic infections (cryptococcosis, Pneumocystis carinii pneumonia, central-nervous-system toxoplasmosis, progressive cutaneous herpes simplex virus infection, disseminated cytomegalovirus infection, candidiasis, or cryptosporidiosis) or Kaposi's sarcoma, or with both. Ten of them died. During the same period five other patients were hospitalized with an illness consistent with a prodrome of the acquired immunodeficiency syndrome (chronic lymphadenopathy, fever, weight loss, and diarrhea). All patients tested had a marked decrease in helper T cells; an inversion of the normal ratio of helper to suppressor T cells, and a decreased or absent blastogenic response of lymphocytes to mitogens. Twenty patients had anergy. There was no evidence of an underlying immunosuppressive disease and no history of blood-product transfusion, homosexuality, or intravenous-drug abuse. This syndrome in patients originating in Central Africa is similar to the acquired immunodeficiency syndrome reported in American patients.